Successful management of acute pulmonary embolism in A cirrhosis patient with variceal Bleeding: A case report

This case reports the management of a 59-year-old male cirrhosis patient combined with variceal bleeding and acute pulmonary embolism (PE). The patient presented with melena for over 10 days and hematemesis for 5 days followed by altered consciousness and shock prior to admission. After emergency treatment, the patient's r bleeding ceased, consciousness was recovered, and hemodynamic stability was achieved. CT examination indicated liver cirrhosis with portal hypertension and esophagogastric varices. Gastroscopy revealed severe esophageal and gastric varices. Significantly elevated D-dimer and FDP levels (53.13 mg/L and 128.4 mg/L, respectively) prompted a pulmonary computed tomography angiography (CTA), which further confirmed the presence of bilateral PE in multiple lobes. The patient (Child-Pugh Class A with 5 points) then received anticoagulation therapy with subcutaneous nadroparin 4100 IU every 12 h in combination with somatostatin, terlipressin (to reduce portal pressure), acid suppression, and rebamipide (for gastric protection). After 8 days of anticoagulation treatment, embolic regression was confirmed by pulmonary CTA and a successful transjugular intrahepatic portosystemic shunt (TIPS) was performed (due to the high risk of endoscopic varicose vein treatment). Oral rivaroxaban 20 mg once daily was administered at the time of discharge and discontinued after 3 months. Grade 3 hepatic encephalopathy occurred 2 weeks later and resolved with symptomatic treatment. One-month follow-up gastroscopy showed mild esophageal varices. A six-month follow-up pulmonary CTA revealed no recurrent PE, rebleeding, or cardiopulmonary vascular events. This case demonstrates that liver cirrhosis with PE may be managed similarly to cirrhosis with portal vein thrombosis (PVT), using individualized approaches. TIPS combined with perioperative anticoagulation (nadroparin and sequential rivaroxaban) may offer superior efficacy and short-/long-term safety compared to endoscopic variceal therapy.